Provider Demographics
NPI:1952669830
Name:DIAZ, JILL RENAE (DC)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:RENAE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9244 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5543
Mailing Address - Country:US
Mailing Address - Phone:703-369-2559
Mailing Address - Fax:703-369-2733
Practice Address - Street 1:9244 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5543
Practice Address - Country:US
Practice Address - Phone:703-369-2559
Practice Address - Fax:703-369-2733
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556990111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor